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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address i�� C1 Sv. TY.yG 13Lyc/ City � /�c J� Lot Size PM Owner's Name SeyL/4 Y QY V ✓� STAddress 9I?C,/ Sv Y �d- Phone Contractor AI!F" /f E/ SoOr Address- , vol License No.yyY�9/ Phone_010y'IVA/-.1i, �--r- .TYP.E OF-WELL-/,PUMP;-.- NEW_WELL-•-✓❑--.- WELE-REPLAC-EMEN•T-O------•--.DESTRUG710N-.(=I _... PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ ° ._DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ' ❑ Gravel Pack ❑ Tracy f)-Type of Casing Specifications f'] Public f ❑ Other ! -vim F Delta Depth of Grout Seal Type of Grout Irrigation Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pumps ` H.P: ". State Work Done_ Well Destruction ❑ < Well Diameter! „'�-*Sealing Material (top 50') `Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION J0.7 REPAIR/ADDITION ! I DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial P"- Other 41141,6 1rh&c1f1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: L i�_Y—A-64A9 Water table depth 8� SEPTIC TANK m Type/Mfg /0"r C.9s7- Capacity /"o No. Compartments x PKG. TREATMENT PLT. ❑ Distance toMethod of Disposal .nearest: Well �� Foundation -' Property Line 419' LEACHING LINE 0 No. & Length of lines " Total length/size /6a7 FILTER BED ❑ Distance totnearest: Well / Foundation Property Line I SEEPAGE PITS Ii Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, staterules and regulations of the San Joaquin Local Health Di1trict. Home owner or licensed agent's signature!certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: OR DEPARTMENT U5>` ONLY Application Accepted byj� Date,- / f Area e Pit or Grout Inspection by Date Final Inspection by ate g r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO K�7 RECEIVED BY DATE PERMIT'NO. +,EH 13-2 (REV.i EH 14-2a I ----------------